Dying rural hospitals affect most vulnerable

When a county is without a hospital, that has lasting effects on the most vulnerable residents. Upshur County has experienced it before, as health care systems have struggled to maintain a hospital there.

East Texas Medical Center Gilmer joins several other hospitals around the country closing primarily because of declining reimbursement rates from Medicare and Medicaid.

Since January 2010, at least 43 rural hospitals have closed across the country, according to the North Carolina Rural Health Research Program.

“I think you’d find that most small cities don’t have hospitals anymore,” said Jeff Ellington, Gilmer city manager. “There was a time when it was pretty common, but it’s becoming less and less common.”

In October, the hospital ceased its inpatient care. By December, officials closed the emergency department, laboratory and imaging services. Most recently, ETMC First Physicians Clinic closed. Four of the clinic’s providers went to nearby facilities, including ETMC hospitals in Quitman and Pittsburg, both deemed critical access hospitals.

“The problem with rural areas is you don’t have the population density to create the demand,” said Steve Dean, a Gilmer resident involved with economic development efforts. “What a hospital needs to survive is a very large customer base of middle-aged people or younger who are well insured.”

Gilmer is Upshur County’s largest city, with a population of more than 5,000. There are many in the bedroom community who are aging, on Medicare or uninsured — challenging factors that can cut into a hospital’s financial viability.

It doesn’t help that the population ranks low for health behaviors, according to the County Health Rankings — an annual project of the University of Wisconsin’s Population Health Institute and the Robert Wood Johnson Foundation.

It ranks 231 out of the 232 rated counties because of a high adult smoking rate, a high adult obesity rate at 31 percent, among other measures.

ETMC EMS had also planned to pull their ambulance services, but city officials fought to keep it there. They’ve worked with a service in Camp County, which will take over ETMC EMS’ contract through 2018 and will be housed in a new facility already under construction. Of all of the services that closed with the hospital, potentially ending an ambulance service was most troubling for residents there.

“That transition has been made on paper,” Ellington said. “ETMC is still the ambulance service and the changeover to Camp County EMS is going to be at the end of this month, on or about March 1.”

Dean has worked with the city’s economic development corporation as a member of the Gilmer Industrial Foundation, a private group that promotes business.

He called a meeting with the group upon news that ETMC would close the location to offer support in finding solutions.

“I wish they’d find a way to come back,” he said.

RURAL HOSPITALS ON LIFE SUPPORT

In the 1980s and 1990s, rural hospitals were financially stressed and 460 closed, research analysis shows. Of the hospitals, 35 percent were in rural areas. Nineteen hospitals would later reopen as acute care hospitals.

Rural hospitals were more likely than larger hospitals to receive Medicare payments under the prospective payment system that were less than the costs associated with treating Medicare patients.

As a response, the federal government modified the system so that rural hospitals would get more funds. Today, rural hospitals face the struggle again. Since 2013, at least 24 rural hospitals have closed.

The Affordable Care Act was designed to provide more access to health care, helping rural hospitals stay afloat. However, new penalties for performance-based measures, such as re-admission rates, stifled already strapped hospitals.

ETMC Gilmer had a loss of more than $2 million in fiscal year 2014, according to Perry Henderson, senior vice president of affiliate operations.

Beginning in fiscal year 2014, there are also fewer funds allotted for indigent care, or disproportionate-share hospital payments, which were based on the premise that more people would be insured through the ACA. However, states such as Texas that chose not to expand Medicaid suffer the most. Of the 15 states where these hospitals have closed since 2013, 10 did not expand Medicaid.

THE VULNERABLE

In Upshur County, about 15.8 percent live below the federal poverty line and 25 percent of children live in poverty. Seniors are vulnerable, too.

Nadine Southerland, 74, is worried because she is prone to falls.

“It’s a shame they couldn’t keep it open,” she said.

When Al and Doris Szameit, moved to Gilmer five months ago, they didn’t imagine they’d live in a community without a hospital. They moved there because of the proximity of the hospital to their senior living complex. Szameit, 83, feels it’s a strange twist of fate.

“This is the third community we’ve moved to where the hospital closed,” he said, noting that they left Brady and Llano after hospitals closed there.

“The reason we want to be near a hospital is I had quadruple bypass heart surgery and I came out of it in very good shape,” Szameit said. “But the doctor said you really should be near a good hospital facility just in case something goes wrong.”

He said he’s lived in large cities around the country but he and his wife wanted to retire in a quiet town. Even with a clean bill of health, there is still an uncertainly.

“So, now we’re frustrated to tears because there’s no hospital and Pittsburg is the closest,” he said. “It is a good hospital but that’s 13, 14 miles away.”

Since Szameit left Brady, he’d learned that another hospital was built, but he can’t handle another move.

“If we had known that we would have stayed there,” he said. “I’m not moving no more. Moving gets harder.”

Sherry Wadlington, 45, of Avinger, is uninsured with little income. In Marion County where she lives, there is no hospital and only one clinic. Most clinics and hospitals nearest her are a 20- to 45-minute drive.

She visited the Gilmer hospital frequently because she has upper respiratory problems. She previously sought primary care in Ore City, which has one physician in private practice and is closer to her Mims community. However, since she’s uninsured and paying cash, her medical bills piled up. Today, she pays what she can as set by her Gilmer doctor’s sliding scale.

She’s not surprised by the hospital closure but will miss the care there. Like many who are uninsured, it was often an alternative to primary care.

“I went to Gilmer because it was usually quicker and closer,” she said. “You could get in and out easier. When you’re broke, it’s easier just to go on and go.”

Even with help through indigent care funds, her emergency room visits still reached the thousands.

She now goes to Good Shepherd Medical Center for emergencies but notes that it’s a challenge to travel between Gilmer and Longview.

“All of my prescriptions are filled in Gilmer, so having to run back and forth is a hassle,” she said.

Her physician is associated with Wellness Pointe, a group that offers medical and dental services in Longview, Kilgore and Gilmer. It’s seen an increase in the patient load since the hospital closing. They’ve also seen more patients presenting with emergencies.

Jeff Brown, director of business development with Wellness Pointe, said the group is considering adding services for minor emergencies.

ATTRACTING HOSPITALS, DOCTORS

The first major effort to bring a hospital to the county was with the Ragland-Fenlaw- Ford Clinic Hospital in 1933. It closed in 1981 and for the next two decades, Baylor Health Care System and Columbia/HCA (now Hospital Corporation of America) both operated the hospital but both struggled to keep it open. During the closings, local doctors had no choice but to send patients to Longview or Tyler hospitals.

“Relationships were created with the Longview and Tyler health care community and the customers basically left Upshur County and went that way,” Dean said.

Before it closed its doors recently, the hospital averaged about two to four patients per day. ETMC officials have said less than 10 percent of the hospitalizations in Upshur County were at the Gilmer hospital.

Dean said it’s difficult to attract new industry to a county with no hospital. Employers may have a hard time enticing potential employees.

“You show him the schools,” he said. “You drive down through town and you see the churches. You drive through the neighborhoods and you get a general feel for the pride that may or may not be there in the town and then you drive by the hospital. Oops, we don’t have one.”

Making a town attractive for health care systems to come in isn’t an easy feat, either.

“In larger cities, it’s possible,” Ellington said. “But in smaller cities it’s not practical. It’s not to say we’re not interested. We’re not in the position to go out and seek someone to come in.”